Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications

Abstract

Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia’s progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.

The impact of point‐of‐care hepatitis C testing in needle and syringe exchange programs on linkage to care and treatment uptake among people who inject drugs: An Australian pilot study

“…While treatment uptake among PWID in Australia has led to a decline in hepatitis C prevalence among people attending needle and syringe programs (NSPs), 13 many PWID remain untreated and are not routinely linked to care. 14,15 PWID face multiple hurdles to accessing treatment in the conventional hepatitis C cascade of care (Figure S1), including the requirement of multiple visits to healthcare providers and pathology services for diagnosis and treatment work-up. [16][17][18] PWID have competing health and socioeconomic priorities and experience stigma in traditional healthcare settings.…”

Increasing national trend of direct-acting antiviral discontinuation among people treated for HCV 2016–2021

“…Overlapping risk factors for treatment discontinuation and loss to follow-up are described 6 , 19 – 21 and could lead to underestimations of treatment discontinuation in clinical studies. With all HCV treatment in Australia delivered through the PBS and half of the estimated population with HCV treated between 2016 and 2021, 22 this analysis provides a highly representative picture of treatment discontinuation at a national level.…”

The Importance of Prisons in Achieving Hepatitis C Elimination: Insights from the Australian Experience

“…In 2020, 3005 hepatitis C treatments were initiated in Australia's prisons, which was estimated to constitute 37% of all treatments nationally [5]. This increase has occurred in direct contrast to the observed decline in treatment uptake in the general community [7]. These statistics underscore both the readiness of people in prison to have their hepatitis C treated and the increasing importance of prison-based hepatitis services in reaching an at-risk population.…”

“…These prospects led the WHO to set goals to eliminate hepatitis C, as a public health threat, by 2030, reducing incidence by 80%, mortality by 65%, and treating 80% of people living with hepatitis C, underpinned by the principle of ‘leaving no-one behind’ [ 4 ]. In HIC, the initial uptake of DAAs among people with known hepatitis C infection was strong; however, as the pool of known cases has been treated over recent years, declines in treatment uptake have been observed—more recently challenged further by the impact of the coronavirus 2019 (COVID-19) pandemic [ 5 , 6 , 7 , 8 , 9 ]. Globally, inequitable access to free or subsidised hepatitis testing, subsidised DAA treatment, and harm and demand reduction interventions, along with poor policy development, implementation, and resourcing, hinders the attainment of the WHO elimination goals for hepatitis C [ 10 ]; 80% of HIC are not on track to achieve hepatitis C elimination by 2030 and poorer nations are unlikely to achieve it [ 6 ].…”